2009 CAUTI guidelines - Centers for Disease Control and Prevention

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For all comparisons, we considered CAUTI outcomes as well as other outcomes critical toweighing the risks and benefits of different catheter management techniques. The evidence forthis question consists of 6 systematic reviews, 37,105,106,182-184 56 RCTs, 60,61,65-69,143,158,158,185-231 34observational studies, 83,85,88,90,96,102,133,167,178,232-258 and 1 economic analysis. 180 The findings of theevidence review and the grades for all important outcomes are shown in Evidence ReviewTable 2C.Q2C.1. Antimicrobial prophylaxisLow-quality evidence suggested no benefit of antimicrobial prophylaxis in patients undergoingshort-term catheterization. 37,60,61,83,85,133,158,178,182,185,186,189-191,232-234 This was based onheterogeneous results for SUTI and bacteriuria/unspecified UTI and no adverse events relatedto antimicrobials. Lack of consistency in specific factors, such as patient population,antimicrobial agents, timing of administration, and duration of follow-up, did not allow for asummary of evidence of the effect of antimicrobial prophylaxis on CAUTI in patients undergoingshort term catheterization. Only two studies evaluated adverse events related to antimicrobials.Our search did not reveal data on antimicrobial resistance or Clostridium difficile infection.Low-quality evidence suggested no benefit of antimicrobial prophylaxis in patients undergoinglong-term catheterization (indwelling and clean intermittent catheterization). 106,183,192,194,235,238This was based on a decreased risk of bacteriuria, heterogeneous results for SUTI, and nodifferences reported for catheter encrustation or adverse events, although data were sparse.One systematic review suggested an increase in antimicrobial resistance with antimicrobial use.Q2C.2. Urinary antisepticsLow-quality evidence suggested a benefit of methenamine for short-term catheterizedpatients. 196,197 This was based on a reduced risk of SUTI and bacteriuria and no differences inadverse events. Evidence was limited to two studies of patients following gynecological surgeryin Norway and Sweden.Very low-quality evidence suggested a benefit of methanamine for long-term catheterizedpatients. 106,236-239 This was based on a reduced risk of encrustation but no differences in risk ofSUTI or bacteriuria. Data on encrustation was limited to one study. Studies involved primarilyelderly and spinal cord injury patients with chronic indwelling cathetersQ2C.3. Bladder irrigationLow-quality evidence suggested no benefit of bladder irrigation in patients with indwelling orintermittent catheters. 66,69,199-206,240-242 This was based on no differences in SUTI andheterogeneous findings for bacteriuria.Q2C.4. Antiseptic instillation in the drainage bagLow-quality evidence suggested no benefit of antiseptic instillation in urinary drainagebags. 90,207-211,243-245 This was based on no differences in SUTI and heterogeneous results forbacteriuria.Q2C.5. Periurethral care42
Low-quality evidence suggested no benefit of antiseptic meatal cleaning regimens before orduring catheterization to prevent CAUTI. 65,67,68,88,158,212-216,246,247 This was based on no differencein the risk of bacteriuria in patients receiving periurethral care regimens compared to those notreceiving them. One study found a higher risk of bacteriuria with cleaning of the urethralmeatus-catheter junction (either twice daily application of povidine-iodine or once daily cleaningwith a non-antiseptic solution of green soap and water) in a subgroup of women with positivemeatal cultures and in patients not receiving antimicrobials. Periurethral cleaning withchlorhexidine before catheter insertion did not have an effect in two studies.Q2C.6. Routine catheter or bag changeLow-quality evidence suggested no benefit of routine catheter or drainage bag changes toprevent CAUTI. 102,217-219,248,249 This was based on no difference or an increased risk of SUTI andno difference in bacteriuria with routine compared to as-needed changes or with more frequentchanging intervals. One study in nursing home residents found no differences in SUTI withroutine monthly catheter changes compared to changing only for obstruction or infection, but thestudy was underpowered to detect a difference. Another study in home care patients found anincreased risk of SUTI when catheters were changed more frequently than monthly.Q2C.7. Catheter lubricantsVery low-quality evidence suggested a benefit of using lubricants for catheter insertion. 167,220-223,250-254 This was based on a decreased risk of SUTI and bacteriuria with the use of a prelubricatedcatheter compared to a catheter lubricated by the patient and a decreased risk ofbacteriuria with use of a lubricant versus no lubricant. Studies were heterogeneous both in theinterventions and outcomes studied. Several studies comparing antiseptic lubricants to nonantisepticlubricants found no significant differences.Q2C.8. Securing devicesLow-quality evidence suggested no benefit of using catheter securing devices to preventCAUTI. 224 This was based on no significant difference in the risk of SUTI or meatal erosion. Theonly study in this category looked at one particular product.Q2C.9. Bacterial interferenceModerate-quality evidence suggested a benefit of using bacterial interference in catheterizedpatients. 225 In the one study evaluating this intervention, urinary colonization with a nonpathogenicEscherichia coli was associated with a decreased risk of SUTI in adults with spinalcord injury and a history of frequent CAUTI.Q2C.10. Catheter cleansingVery low-quality evidence suggested a benefit of wet versus dry storage procedures forcatheters used in clean intermittent catheterization. 255 This was based on a decreased risk ofSUTI with a wet storage procedure in one study of spinal cord injury patients undergoing cleanintermittent catheterization compared to a dry storage procedure where the catheter was left toair dry after washing. In the wet procedure, the catheter was stored in a dilute povidone-iodinesolution after washing with soap and water.Q2C.11. Catheter removal strategies43
Page 4 and 5: AcknowledgementHICPAC thanks the fo
Page 6 and 7: AbbreviationsADLAPACHE IIASAASBBUNC
Page 8 and 9: I. Executive SummaryThis guideline
Page 10 and 11: II. Summary of RecommendationsTable
Page 12 and 13: II. Proper Techniques for Urinary C
Page 14 and 15: 1. If obstruction is anticipated, c
Page 16 and 17: a. Procedure-specific guidelines fo
Page 18 and 19: III. Implementation and AuditPriori
Page 20 and 21: IV. Recommendations for Further Res
Page 22 and 23: V. BackgroundUrinary tract infectio
Page 24 and 25: acteriuria inevitably occurs over t
Page 26 and 27: VII. MethodsThis guideline was base
Page 28 and 29: Figure 2: Results of the Study Sele
Page 30 and 31: After determining the GRADE of the
Page 32 and 33: Category I recommendations are defi
Page 34 and 35: VIII. Evidence ReviewQ1. Who should
Page 36 and 37: Evidence Review Table 1B. What are
Page 38 and 39: Very low-quality evidence suggested
Page 40 and 41: Q2B.2. Hydrophilic catheters vs. st
Page 44 and 45: a. Clamping vs. free drainage prior
Page 46 and 47: studies. 3,25,260-276 The findings
Page 48 and 49: 2D.5. Maintain unobstructed urine f
Page 50 and 51: 15. Jain P, Parada JP, David A, Smi
Page 52 and 53: 44. Chaudhuri P, Vengadasalam D. Ur
Page 54 and 55: 71. Kelleher RE, Meeropol E, Parks
Page 56 and 57: 101. Hirsh DD, Fainstein V, Musher
Page 58 and 59: 132. Van Nagell, JR, Penny RM, Rodd
Page 60 and 61: 163. Lai KK, Fontecchio SA, Lai KK,
Page 62 and 63: 193. Waites KB, Canupp KC, Armstron
Page 64 and 65: 222. Cohen A. A microbiological com
Page 66 and 67: 253. Chavigny KH. The use of polymi

2009 CAUTI guidelines - Centers for Disease Control and Prevention

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